A nurse on a postpartum unit is caring for a group of clients. Which of the following clients is the nurse’s priority?
A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus.
A client who is 3 days postpartum and has not had a bowel movement since prior to admission.
A client who is 4 days postpartum and has lochia serosa.
A client who is 1 day postpartum and has not voided in 8 hr.
The Correct Answer is D
A client who is 1 day postpartum and has not voided in 8 hr. This client is at risk of urinary retention, bladder distension, and infection due to the effects of epidural anesthesia, perineal trauma, and fluid shifts after delivery. The nurse should assess the client’s bladder and catheterize if necessary.
Choice A is wrong because a client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus is showing a normal finding.
The fundus should descend about 1 to 2 cm per day after delivery and be nonpalpable by day 10.
Choice B is wrong because a client who is 3 days postpartum and has not had a bowel movement since prior to admission is not uncommon.
Constipation is a common problem after delivery due to decreased peristalsis, dehydration, and fear of pain.
The nurse should encourage fluid intake, fiber intake, and early ambulation to promote bowel function.
Choice C is wrong because a client who is 4 days postpartum and has lochia serosa is also showing a normal finding.
Lochia serosa is the pinkish-brown discharge that occurs from day 4 to 10 after delivery.
It consists of old blood, serum, leukocytes, and tissue debris.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should begin discharge planning upon the client’s admission. This is because discharge planning is a key aspect of effective care that reduces the length of stay, emergency readmissions and pressure on hospital beds. Discharge planning involves considering what support might be required by the client in the community, referring the client to these services, and liaising with these services to manage the client’s discharge.
Choice A is wrong because the nurse is not responsible for providing a written prescription for a client home care referral. This is the role of the provider or another authorised prescriber.
Choice C is wrong because a home hazard appraisal does not include an assessment of the client’s financial resources. A home hazard appraisal is an evaluation of the safety and accessibility of the client’s home environment.
Choice D is wrong because a medication reconciliation is not required 24 hours prior to the client’s discharge. A medication reconciliation is a process of comparing the medications a client is taking with those prescribed for them to avoid errors or discrepancies. A medication reconciliation should be done at every transition of care, including admission, transfer and discharge.
Correct Answer is B
Explanation
Encourage the client to visit with someone who has had an amputation.
This strategy can help the client cope with the loss of a body part and learn from the experience of others who have gone through a similar situation.
Choice A is wrong because suggesting that the client wear facility clothing until the prosthesis fitting can delay the client’s acceptance of the body image alteration and increase the risk of infection.
Choice C is wrong because discouraging the client from touching the residual limb for the first week can interfere with the healing process and prevent the client from becoming familiar with the new body part.
Choice D is wrong because reassuring the client that the rehabilitation program is optional can discourage the client from participating in physical therapy and hinder the recovery and adaptation.
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